Attachment and physical health Flashcards
What is the Human Systems of Homeostasis?
Act to balance internal and external factors that may affect a system and keep it functioning within certain parameters
What are some regulatory systems that affect mental health?
Function:
Emotional Regulation
Systemic arousal/ energy conservation
Memory
Perception
Sleep /Wake cycle
Anatomical/Physiological Systems:
Limbic system
Autonomic system
Hippocampus/ Median Temporal lobe and Brain stem
Temporal Lobes and visual cortex
Pituitary /Endocrine
wHAT IS THE limbic system concerned with?
Concerned with the modulation of Emotions and Instincts
What does emotional dysregulation look like?
Extreme emotional outbursts
Uncontrolled temper
Self Harm
Difficulty maintaining relationships
Which parts of the nervous are involved in hyperarousal and hypoarousal?
Hyperarousal – Sympathetic Nervous system
Hypoarousal - Parasympathetic Nervous system
What are the causes of dysregulation?
Disrupted Attachment
Psychological Trauma (post Traumatic stress Disorder)
Temporary Effect of Trauma, Life Event or Stress
How was the attachment theory developed?
Bowlby First described concept: Human and animals attached to caregiver who feeds them
Lorenz ‘52– goslings follow parent not for food
Harlow ’58 – monkeys bond to cuddly pole with food rather than wire food pole
What is the theory behind attachment theory?
Attachment functions to protect infant from external dangers eg predators
Probable also emotional connection itself gives meaning/ has importance for our functioning
Social Animals
Essential for development of child
Affects individual through lifecycle
What is the neurophysiology behind attachment theory?
Oxytocin
Area of brain mainly involved limbic system and Right Hemisphere
Autonomic System Regulation - Separation – increase pulse and decreased temperature. If prolonged or frequent can lead to changes in cortisol and so affects bodies response to stress eg increase in infection
What is the window of tolerance
Window between 2 different bodily crises of hyper arousal - between flight/flight and freeze/dissociation
What are the types of attachment styles
Secure
Anxious
Ambivalent
Avoidant
What can affect attachment?
Iry caregiver emotionally unavailable eg depression
Drugs/ alcohol
Abuse/neglect
Anxious
Ambivalent
Avoidant
What is the secure attachment style?
Able to internally self regulate the emotional neural systems and response to environment From about 5 years upwards
Develop reciprocal social bonds
What is the anxious attachment style?
Maintaining attachment with a caregiver who is unpredictable
Clingy
What is the ambivalent attachment style
Alternate clinging with excessive submissiveness to no trust
Role reversal – parent cared for by child
Dysregulation of fear and anger
What is the avoidant attachment style
Child tries to minimise need for attachment to avoid rebuff
Remains in distant contact with the caregiver
When severe can ‘freeze’ when reunited with parent
How can we treat certain attachment styles?
NB Brain remains ‘plastic’ into early 20’s
Treatment (Dialectic Behaviour Therapy) can change pattern
Treat co- morbidities eg depression, self harm, eating disorders
Elana is in frequent trouble at school for aggressive outbursts. She is often in fights with her peers.
Elana’s mother had severe obsessive compulsive disorder Elana was often left crying and hungry.
Support was sought from Elana’s paternal grandparents and treatment accessed by her Mum
Elana presents with a three year history of drug misuse, self harm and suicide attempts.
She also presents with low mood and pseudohallucinations
In addition she presents with food restriction, vomiting and weight loss
Elana has been admitted twice with ongoing low mood after taking overdoses and with severe weight loss and refusal to eat.
Elana has now been discharged from hospital but her eating remains restricted . She has no suicidal ideas and her mood has improved.
She is taking Fluoxetine and engaged in Dialectic Behaviour therapy
What do you think the diagnosis may be? (there may be more than one)
Eating Disorder
Depression
Drug Misuse
Attachment Disorder/Emerging personality disorder/borderline personality disorder
Elana is in frequent trouble at school for aggressive outbursts. She is often in fights with her peers.
Elana’s mother had severe obsessive compulsive disorder Elana was often left crying and hungry.
Support was sought from Elana’s paternal grandparents and treatment accessed by her Mum
Elana presents with a three year history of drug misuse, self harm and suicide attempts.
She also presents with low mood and pseudohallucinations
In addition she presents with food restriction, vomiting and weight loss
Elana has been admitted twice with ongoing low mood after taking overdoses and with severe weight loss and refusal to eat.
Elana has now been discharged from hospital but her eating remains restricted . She has no suicidal ideas and her mood has improved.
She is taking Fluoxetine and engaged in Dialectic Behaviour therapy
What subspecialty would you refer to in AMH?
) Eating Disorder Service, Access Team, Drug Misuse service, Personality Disorder service…
Co-Ordinator is essential
Elana is in frequent trouble at school for aggressive outbursts. She is often in fights with her peers.
Elana’s mother had severe obsessive compulsive disorder Elana was often left crying and hungry.
Support was sought from Elana’s paternal grandparents and treatment accessed by her Mum
Elana presents with a three year history of drug misuse, self harm and suicide attempts.
She also presents with low mood and pseudohallucinations
In addition she presents with food restriction, vomiting and weight loss
Elana has been admitted twice with ongoing low mood after taking overdoses and with severe weight loss and refusal to eat.
Elana has now been discharged from hospital but her eating remains restricted . She has no suicidal ideas and her mood has improved.
She is taking Fluoxetine and engaged in Dialectic Behaviour therapy
What are your main areas of concern/risk for Elana?
Risk of relapse of eating disorder, drug misuse or mood disorder and self harm.
Care in labelling of Personality disorder when young
Elana is in frequent trouble at school for aggressive outbursts. She is often in fights with her peers.
Elana’s mother had severe obsessive compulsive disorder Elana was often left crying and hungry.
Support was sought from Elana’s paternal grandparents and treatment accessed by her Mum
Elana presents with a three year history of drug misuse, self harm and suicide attempts.
She also presents with low mood and pseudohallucinations
In addition she presents with food restriction, vomiting and weight loss
Elana has been admitted twice with ongoing low mood after taking overdoses and with severe weight loss and refusal to eat.
Elana has now been discharged from hospital but her eating remains restricted . She has no suicidal ideas and her mood has improved.
She is taking Fluoxetine and engaged in Dialectic Behaviour therapy
How would you go about transitioning her?
Early referral important
Care co-ordinater
Transition meetings with Elana present
What are some forms of SMI (Severe mental illness?)
Primary focus on Severe/Serious Mental Illness (SMI)
“Psychological problems that are often so debilitating that their ability to engage in functional and occupational activities is severely impaired”
Commonest disorders - schizophrenia and bipolar disorder, major depressive disorder
Cross-age prevalence ~0.7-0.9%
Drug and alcohol abuse
Dementia/Delirium (not focussed on during this talk, but delirium is a major contributor to morbidity/mortality)
What are some physical co-morbidities in SMI?
Poor physical health is common
SMI patients are more likely (1.3x for females, 1.2x for males) to have one or more physical health conditions than all patients
Differences more pronounced in younger age groups
Highest health inequality in ages 15-34 for asthma, diabetes, HTN, obesity
SMI patients aged 15-34 are 5x more likely to have 3 or more health conditions
Inequalities persist for obesity, asthma, diabetes, COPD, CHD and stroke after controlling for deprivation, age and sex
What is the impact of SMI on mortality?
Patients with SMI have a higher premature mortality than the general population
Average reduction in life is 15-20 years in SMI
Schizophrenia – 10-20 years
Bipolar Disorder – 9-20 years
Drug and alcohol use – 9-24 years
Recurrent depression – 7-11 years
Heavy smoking – 8-10 years
Death rate for those under 75years old is 3.7x higher than the general population
Estimated that 2/3 deaths are from preventable physical illnesses
Compared to general population, under 75s with SMI have death rates:
5 times higher for liver disease
4.7 times higher for respiratory disease
3.3 times higher for cardiovascular disease
2 times higher for cancer
Other causes of death include:
Suicide, substance abuse, accidents, dementia, infections
Why does SMI have such a big impact on morbidity?
Effects of mental illness
Effects of prescribed medication
Effects of social circumstance
Effects of lifestyle
Effects of the healthcare system
What are the effects of mental illness on morbidity?
Direct effect of symptoms of mental disorder on physical healthcare
Schizophrenia/psychosis
Delusional beliefs about physical health
Delusions of causes of physical disorders
Paranoia/persecutory beliefs about healthcare staff
Delusional beliefs around treatments/medications
Chronic thought disorder leads to challenging engagement
Negative symptoms
- Amotivation
- Social withdrawal
- Cognitive impairment
Major Depressive Disorder
Amotivation
Apathy
Beck’s Cognitive Triad (negative thoughts about the world, self and future)
Worthlessness/hopelessness/guilt
Anxiety
Significant social anxiety – not leaving home/secure address
Dementia
Cognitive impairments
lack of concordance with medication
Missed appointments
What are the effects of prescribed medication on morbidity?
Many psychotropic medications have impacts on physical illness
Metabolic Syndrome
Type 2 Diabetes Mellitus
CVD
Bone Mineral Density Loss
Renal Disease
Thyroid Disease
Other miscellaneous disorders
What is metabolic syndrome?
Clustering of abnormalities
Central obesity
Hypertension
Dyslipidaemia
Glucose Intolerance/Insulin Resistance
Hypertension
5-6 fold increase in risk of developing T2DM
3-6 fold increase in risk of mortality due to CVD
May be an aetiological factor in some cancers (particularly colon cancer
Prevalence of metabolic syndrome
Prevalence in schizophrenia varies in studies, depending on multiple factors (MetS criteria, gender, ethnicity, country, age group, antipsychotic treatment)
Prevalence ~19.4 - 68%!
Higher prevalence in schizophrenia compared to general population
Bipolar disorder prevalence ~ 22-30%
Caused/exacerbated by various antipsychotics (particularly atypicals)
What can cause obesity/ weight gain in SMI?
Antipsychotics
Clozapine/Olanzapine
Quetiapine/Risperidone (intermediate risk)
Antidepressants
Mirtazapine, paroxetine
Mood Stabilisers
Lithium, Valproate
Linked to metabolic syndrome, general poor health
Other meds of course linked, but these are common ones
T2DM on SMI
Atypical antipsychotics higher risk than typicals
Atypical D2 receptor antagonism may have direct effect on development of glucose intolerance (initially via blunted insulin secretory response)
Olanzapine/Clozapine highest risk
Risperidone intermediate risk
Antidepressants may increase risk
Likely due to side-effects of increased appetite/sedation/weight gain
Bone mineral density loss in SMI
Many antipsychotics lead to raised prolactin levels
It is suggested that hyperprolactinaemia leads to BMD loss
although studies are contradictory
May be more related to lifestyle issues
Smoking, reduced physical activity, reduced vitamin D production, alcohol abuse
High risk factor for fractures
Hip fractures are related to high morbidity/mortality
Other fractures may precipitate pain/further loss of mobility and independence
What are some msicellaneous drug-related disorders?
Lithium
Clinical hypothyroidism (up to 47% of patients!)
Renal failure
Clozapine
Agranulocytosis
Myocarditis
Chronic severe constipation (spontaneous bowel perforation)
What are the effects of social circumstance?
Health generally worse in deprived communities
Life expectancy lower in deprived communities
Prevalence/Incidence of psychotic disorders 2.5-3.1x higher in most deprived areas compared to least deprived areas
Social drift theory
Symptoms of SMI/deterioration of cognitive functioning leads to difficulties with functioning and maintenance of living standards
Individuals with SMI “drift” into progressively lower socioeconomic bands and/or areas with increased deprivation
Social isolation leads to reduced contact with healthcare professionals
Reluctance to attend check-ups/health visits
Cognitive difficulties
Poor interactions with healthcare professionals
Detentions under MHA
Poor interactions in general health wards/A&E can be related to stigma
Effects of lifestyle on co-morbidity in SMI
Smoking!
Smoking reducing in general population, but stable in SMI
Some studies suggest ~60% of adults with schizophrenia are regular tobacco smokers
Poor diet
Lack of exercise
Amotivation
Social isolation
Cognitive dysfunction
Stigma
Drug and alcohol use
~41% dual diagnosis
Direct physical illness
Liver disease
Brain damage (e.g. Wernicke/Korsakoff disease)
Accidental overdose
Related illness
VTE
HIV
Hepatitis/BBV
What are the effects of the healthcare system on morbidity with SMI?
Division of healthcare system and training into silos
Psychiatrists focus on mental over physical health
De-skilling psychiatrists in physical medicine
Poor communication due to separation of physical/mental health wards
Completely different sites – RHH/NGH vs MCC/Longley
Who is responsible for monitoring of physical health?
GPs?
Psychiatrists (given number of physical risks of psychotropic meds)?
Lower level of healthcare intervention in SMI
Lower rates of cardiac stenting or bypass grafting in schizophrenia with CVD
People with psychosis are less likely to receive warfarin following CVA
SMI patients less likely to receive routine cancer screening
Standard of diabetes care is likely to be lower in SMI
Related to patient-level effects (as described before)
But also… stigma
What is diagnostic overshadowing?
Initially in LD patients
Assumption that behaviour is due to their learning disability rather without exploring biological determinants
Can be extended to SMI/Dementia/Delirium
Once a patient has a diagnosis, all new symptoms are assumed to be due to that
Woman on AMU with a history of depression, presented with confusion, fever, cough.
Medical team referred to psych as she was refusing blood tests and thought confusion must be mental illness, without assessing for delirium/sepsis
How can we target health behaviours and MetS (Metabolic syndrome)?
Targeting health behaviours
Smoking
Poor diet
Lack of exercise
Targeting signs of Metabolic Syndrome (MetS)
Obesity
BP
Glucose Regulation
Blood Lipids
Further interventions for SMI
Actively and effectively treat psychiatric illness
Appropriate treatment at appropriate dose
Proactive treatment of symptoms with aim for functional recovery
Active treatment of comorbid substance misuse
STOMP/STAMP
Stopping overmedication of young people with LD/autism or both
Initially an LD/Paediatric initiative, but applicable to adult/OA psychiatry
Does this patient really need this medication at this dose?
Patient education about risk factors and management of diseases
Diabetes courses
Healthy heart information
Awareness training (this session) and reduction of stigma in healthcare professions
?Review of healthcare systems and how these are organised
Reduction in silo-ing and integrated physical/mental healthcare
